HA Exam I |50 Questions| With Correct Answers.
Which item is not considered a therapeutic communication technique?
The "five why" question
While conducting a physical examination for a client with asthma, the nurse notes
that the client is wheezing and documents this finding in the medical record.
Which type of data does the physical examination and diagnostic tests provide?
Objective
The nurse is admitting a client of the Islam faith during the holy month of
Ramadan. The client tells the nurse that he must fast during this time. Which
response by the nurse is the most appropriate?
"What can we do to accommodate your needs during your stay here?"
The nurse is calculating the percent weight change of an adult client, weighing
156 pounds 1 month ago, and 140 pounds on current examination. Which percent
of weight change will the nurse document for the client in the medical record?
Change in mass/ original = 10%
The nurse manager is preparing for an accreditation visit and wants to ensure
staff understand what culturally/spiritually responsive nursing care is, which
statement describes culturally/spiritually responsive nursing care?
Delivery of care that transcends cultural boundaries and considers a client's culture and
spirituality affects on health, illness and lifestyle
During a health history the nurse would like to review a client's medications.
Which question is most important to ask when gathering the medication history?
"can you tell me about the over-the-counter, prescription, and non-prescriptions
medications you take?"
During an interview with an older adult client, the nurse notes the client is
confused as to date and time. The nurse document this finding as an indicator of
which item?
Orientation
The nurse is completing a self-assessment to determine cultural competence.
Which behavior indicates cultural competence?
Permitting a Bedouin to sleep on the floor
A nurse caring for a client for the first time should perform which assessment,
first, before attempting to position or move the client.
A mobility assessment
While being interviewed, a client admits to the nurse that she has been hearing
voices and sounds for the past three days. Which response by the nurse is the
most appropriate?
Tell me about what the voices tell you to do.
A nurse is admitting a client who has a fractured femur obtain a blood pressure
reading of 140/94 mmHg. The client denies any history of hypertension. Which of
the following should the nurse take first?
Ask the client if she is having pain.
A nurse is introducing their self to a client as the first step of a comprehensive
physical examination. Which of the following strategies should the nurse use with
this client?
, Use a mix of open and closed ended questions.
Reduce environmental noise
Perform the general survey before the examination
Have the client complete a printed history form
3. The nurse is interviewing the client. The nurse says to the client, "it sounds like
you don't like your new job because it's more stressful than you anticipated."
Which communication technique is the nurse using in this interaction with the
client?
Paraphrasing
A nurse educator is reviewing proper body mechanics during student nurse
orientation. Which of the following statements should the nurse educator identify,
as an indication the student nurses understands the teaching (select all that
apply)?
To broaden my base of support, I should spread my feet apart.
The lower my center of gravity, the more stability I have
The nurse is reviewing the plan of care for a client who was admitted for suicidal
tendencies. The nurse documents that the client is no longer experiencing
thoughts of hurting self. Which step of the nursing process is the nurse using?
Evaluation
During the assessment of an adult client's blood pressure, the nurse notes the
following on the sphygmomanometer: first faint tapping sounds at 136, swishing
sounds at 120, clear tapping sounds at 108, muffled sounds at 98, and silence at
76. This nurse would document this client's blood pressure as
136/76
A charge nurse is assigning rooms for the clients to be admitted to the unit. To
prevent falls, which of the following clients should the nurse assign to the room
closest to the nurse's station?
An older adult who has postoperative bleeding following a below-the-knee amputation
The nurse is obtaining information about a client's past health history. Which is
not considered part of the past health history?
Advanced directive
The join commission (2010) requires that an interpreter be available in health care
facilities. The nurse is performing a health assessment and does not speak the
language of the client. What is the most appropriate action the nurse should
take?
Use a facility approved interpreter.
The nurse conducts a health history while admitting a cognitive intact client to
the acute care facility. Which type of data does the health history provide the
nurse about the client?
Subjective
While conducting a review of systems assessment during a health history, which
question is appropriate?
Which item is not considered a therapeutic communication technique?
The "five why" question
While conducting a physical examination for a client with asthma, the nurse notes
that the client is wheezing and documents this finding in the medical record.
Which type of data does the physical examination and diagnostic tests provide?
Objective
The nurse is admitting a client of the Islam faith during the holy month of
Ramadan. The client tells the nurse that he must fast during this time. Which
response by the nurse is the most appropriate?
"What can we do to accommodate your needs during your stay here?"
The nurse is calculating the percent weight change of an adult client, weighing
156 pounds 1 month ago, and 140 pounds on current examination. Which percent
of weight change will the nurse document for the client in the medical record?
Change in mass/ original = 10%
The nurse manager is preparing for an accreditation visit and wants to ensure
staff understand what culturally/spiritually responsive nursing care is, which
statement describes culturally/spiritually responsive nursing care?
Delivery of care that transcends cultural boundaries and considers a client's culture and
spirituality affects on health, illness and lifestyle
During a health history the nurse would like to review a client's medications.
Which question is most important to ask when gathering the medication history?
"can you tell me about the over-the-counter, prescription, and non-prescriptions
medications you take?"
During an interview with an older adult client, the nurse notes the client is
confused as to date and time. The nurse document this finding as an indicator of
which item?
Orientation
The nurse is completing a self-assessment to determine cultural competence.
Which behavior indicates cultural competence?
Permitting a Bedouin to sleep on the floor
A nurse caring for a client for the first time should perform which assessment,
first, before attempting to position or move the client.
A mobility assessment
While being interviewed, a client admits to the nurse that she has been hearing
voices and sounds for the past three days. Which response by the nurse is the
most appropriate?
Tell me about what the voices tell you to do.
A nurse is admitting a client who has a fractured femur obtain a blood pressure
reading of 140/94 mmHg. The client denies any history of hypertension. Which of
the following should the nurse take first?
Ask the client if she is having pain.
A nurse is introducing their self to a client as the first step of a comprehensive
physical examination. Which of the following strategies should the nurse use with
this client?
, Use a mix of open and closed ended questions.
Reduce environmental noise
Perform the general survey before the examination
Have the client complete a printed history form
3. The nurse is interviewing the client. The nurse says to the client, "it sounds like
you don't like your new job because it's more stressful than you anticipated."
Which communication technique is the nurse using in this interaction with the
client?
Paraphrasing
A nurse educator is reviewing proper body mechanics during student nurse
orientation. Which of the following statements should the nurse educator identify,
as an indication the student nurses understands the teaching (select all that
apply)?
To broaden my base of support, I should spread my feet apart.
The lower my center of gravity, the more stability I have
The nurse is reviewing the plan of care for a client who was admitted for suicidal
tendencies. The nurse documents that the client is no longer experiencing
thoughts of hurting self. Which step of the nursing process is the nurse using?
Evaluation
During the assessment of an adult client's blood pressure, the nurse notes the
following on the sphygmomanometer: first faint tapping sounds at 136, swishing
sounds at 120, clear tapping sounds at 108, muffled sounds at 98, and silence at
76. This nurse would document this client's blood pressure as
136/76
A charge nurse is assigning rooms for the clients to be admitted to the unit. To
prevent falls, which of the following clients should the nurse assign to the room
closest to the nurse's station?
An older adult who has postoperative bleeding following a below-the-knee amputation
The nurse is obtaining information about a client's past health history. Which is
not considered part of the past health history?
Advanced directive
The join commission (2010) requires that an interpreter be available in health care
facilities. The nurse is performing a health assessment and does not speak the
language of the client. What is the most appropriate action the nurse should
take?
Use a facility approved interpreter.
The nurse conducts a health history while admitting a cognitive intact client to
the acute care facility. Which type of data does the health history provide the
nurse about the client?
Subjective
While conducting a review of systems assessment during a health history, which
question is appropriate?
